Integrated Treatment Program May Be Best Approach For Comorbid PTSD and Substance Dependence

Study participants who received an integrated treatment for posttraumatic stress disorder (PTSD) and substance dependence plus usual treatment for substance dependence showed significantly greater reductions in PTSD symptom severity compared with participants who only received usual treatment for substance dependence, according to a study in the August 15 issue of JAMA, a theme issue on violence and human rights.

“Prolonged exposure therapy, a cognitive-behavioral therapy involving exposure to memories and reminders of past trauma, has long been regarded as a gold standard treatment for PTSD,” according to background information in the article. There is a concern, however, that exposure therapy may be inappropriate because of risk of relapse for patients with co-occurring substance dependence. “There is, however, an absence of evidence to support or refute this recommendation, because most trials of PTSD treatment have excluded individuals with substance dependence.”

Katherine L. Mills, Ph.D., of the University of New South Wales, Sydney, Australia, and colleagues conducted what is believed to be the first randomized controlled trial of an integrated treatment for PTSD and substance dependence that incorporates prolonged exposure therapy. The study enrolled 103 participants who met criteria for both PTSD and substance dependence. Participants were recruited from 2007-2009; outcomes were assessed at 9 months, with interim measures collected at 6 weeks and 3 months. Participants were randomized to receive either an integrated treatment for PTSD and substance dependence called Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE), plus usual treatment for substance dependence (n = 55); or usual treatment alone (control) (n = 48). COPE consists of 13 individual 90-minute sessions (i.e., 19.5 hours) with a clinical psychologist.

The primary outcomes measured were changes in severity of PTSD symptoms and substance dependence.

The researchers found that from the beginning of the study to 9-month follow-up, significant reductions in PTSD symptom severity were found for both the treatment group and the control group; however, the treatment group demonstrated a significantly greater reduction in PTSD symptom severity compared with the control group.

By the 9-month follow-up, rates of substance dependence had decreased to 45.4 percent in the treatment group and 56.2 percent in the control group; however, the difference between groups was not statistically significant. Both the treatment and the control group also demonstrated significant reductions in severity of dependence from baseline to 9-month follow-up; however, the degree of change did not differ significantly between groups. Also, there were not any significant between-group differences in relation to changes in substance use, depression, or anxiety.

The researchers write that it is important to note that most participants randomized to receive COPE plus usual treatment continued to use substances throughout the study.

“These findings challenge the widely held view that patients need to be abstinent before any trauma work, let alone prolonged exposure therapy, is commenced. Although we agree that patients need to show some improvement in their substance use and an ability to use alternative coping strategies before prolonged exposure therapy is initiated, findings from the present study demonstrate that abstinence is not required.”